Uterus endometrial and myometrial malignancies

Background

Total abdominal hysterectomy (TAH) is undertaken for the treatment of a number of medical conditions, ranging from prolapse of the uterus to benign or malignant lesions in the body of the uterus, cervix and/or ovaries.^1-4 Obstetric removal of the uterus may occur due to intractable haemorrhage, rupture or abnormal placental implantation.⁴

This protocol includes hysterectomy for endometrial and myometrial malignancies. See separate protocols for hysterectomies for invasive tumours of the cervix and benign conditions.

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Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

See general information for more detail on specimen handling procedures.

Inspect the specimen and dictate a macroscopic description.

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External Inspection

Orientate and identify the anatomical features of the specimen.

Photograph the intact specimen if required.

Describe the following features of the specimen:

Procedure

Record as stated by the clinician.

Specimen integrity

• Intact
• Opened, describe
• Morcellated,⁴ describe

Laparoscopic specimens may be received in pieces and should be orientated where possible to resemble intact uterus.⁴

Anatomical components included (more than one may apply) and specimen size (mm)

Describe and measure the anatomical components present.¹

Refer to relevant specimen protocol(s) for more detail.

Uterus

• Measure in three dimensions^1,5
• Mid-line fundal-serosa to ectocervix
• Maximum intercornual
• Maximum anterior to posterior

Cervix

• Measure in two dimensions, anterior-posterior (12 to 6 o’clock) x transverse (3 to 9 o’clock ).

Serosal surface^3,5

Describe:¹

• Normal
• Abnormal
  • Nodules
  • Adhesions
  • Perforation present
  • Tumour present

Uterus weight (g)^1,5

• Weight of specimen without ovaries or fallopian tubes

Ovary^1,6

• Specify laterality, measure each in three dimensions and describe
• If abnormal, see separate ovary and fallopian tube protocol

Fallopian tube(s)¹

• Specify laterality, measure each in two dimensions (length x diameter) and describe⁵
• If abnormal, see separate ovary and fallopian tube protocol

Omentum¹

• Measure in three dimensions and describe
• If present describe and measure tumour deposits (as a minimum measure the size of the largest deposit, if extensive replacement include the proportion (%) of fat replaced by tumour)

Peritoneal biopsies, per site (usually received separately)¹

• Measure in three dimensions

Other tissues

• Measure and describe according to applicable protocol

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Dissection

The surgical margins and any abnormal serosal surfaces of the uterus should be painted with ink to assess areas suspicious for tumour involvement. In radical hysterectomy specimens the parametrium and vaginal cuff must be inked.

Consider taking parametrial sections after inking and before opening the uterus to avoid contamination.

Upon receipt of the specimen, the uterus must be promptly opened along the lateral uterine walls (3 to 9 o’clock) and placed in formalin within an hour to ensure adequate fixation.

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Internal Inspection

Describe the cut surface appearance of the uterus including the following items⁴

Tumour

• Absent
• Present
  • Number; if more than one tumour, designate and describe each tumour separately

Tumour site^1,5

• Describe location in the endometrium
  • Anterior
  • Posterior
  • Fundal
  • Left lateral wall
  • Right lateral wall
  • Left cornu
  • Riht cornu
  • Isthmus
• Other, describe

Tumour size (mm)

• In three dimensions¹

Endometrial tumours should be measured superior-inferior x transverse x thickness, where thickness is total of exophytic plus endophytic tumour.¹

Tumour appearance

• Exophytic
• Endophytic
• Haemorrhagic
• Necrotic

Myometrial invasion

• No
• Yes
  • Maximum depth of invasion (mm)⁵
  • Thickness of adjacent normal myometrium (mm)^1,5
  • Minimum distance to serosal surface (mm)

Endometrium

• Thickness (mm)

Other endometrial abnormalities, residual endometrium

• Absent
• Present, describe
  • Polyp(s)
  • Atrophy
  • Other, describe

Distance to margins (mm)

• Distance of tumour to the inferior surgical margin (mm)¹

Cervical involvement

Specify if tumour is in continuity with endometrial lesion:⁵

• No
• Yes

Measure (mm):¹

• Tumour size in three dimensions (superior-inferior x transverse x thickness where thickness is exophytic plus endophytic)¹
• Distance of tumour to inferior and radial surgical margins¹
• Maximum depth of cervical wall invasion and total cervical wall thickness in the region of maximal invasion¹

See separate protocol for invasive tumours of the cervix.

Other abnormalities

Leiomyomas with atypical macroscopic features require thorough sampling to exclude malignancy. See separate protocol for benign uterus for more detail.

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Processing

Dissect the specimen further and submit sections for processing according to the diagram provided.

Submit representative sections of:

• Submit left and right parametrial tissue:
  Paint both parametrial margins with ink and section perpendicularly into sequential slices or if minimal or no parametrium present, submit shave sections of the parametrial margin.⁶ Ideally parametrial sections are taken after inking but before opening the uterus (to avoid contamination).
• Ovaries: if normal size and macroscopically normal in appearance both ovaries should be sectioned in 2-3mm intervals perpendicularly to the long axis andideally submitted in their entirety;⁶ although if this is not possible two sections are a minimum. The entire ovaries should be submitted in endometrial serous carcinoma, clear cell carcinoma, carcinosarcoma and familial cancer syndromes (Lynch syndrome and BRCA).⁶
• If fallopian tubes are unremarkable, ideally the entire tubes are submitted using the SEE-Fim protocol.⁶ Representative tumour sections if involved.
• Tumour: submit 1 section per cm of tumour, with a minimum of 4 blocks demonstrating
  • Full thickness (composite if required) section of the uterine wall including serosa at the deepest point of invasion
  • Relationship to serosa
  • Surgical margin(s), including ectocervical or vaginal
  • Tumour/non-tumour interface
  • additional sections if myoinvasion is difficult to assess, for example in cases of adenomyosis or cornual tumour
• Submit 1 section per cm of tumour, with a minimum of 4 blocks.
• The entire endometrium is submitted
  • If no tumour is identified in the setting of a history of atypical hyperplasia or endometrial carcinoma
  • In cases of Lynch syndrome and include entire isthmic region⁶
    Submit endometrium with the adjacent inner myometrium (excess myometrium can be trimmed), and cornual sections.
• At least one representative section of uninvolved endometrium.
• Isthmic sections, if uninvolved, sagittal one midline anterior and posterior. If involved, additional sections may be required to assess tumour parameters.  All isthmic tissue should be submitted in cases of Lynch Syndrome.
• Cervix, if uninvolved, sagittal one midline anterior and posterior ensuring sampling of endocervical canal.
• Cervix, if involved submit at least 2 blocks including full thickness of cervical wall and ectocervical or vaginal cuff margin and radial stromal. 

Submit all peritoneal biopsies in their entirety, serially sectioned if >4mm (usually received separately). See also gynaecological small biopsy protocol.

Submit all lymph nodes and identify the site of each.

• ≤2mm in size submit whole
• ≥3mm in size section in 2mm slicing perpendicular to the long axis submitting in their entirety

Sentinel lymph nodes:

• As non-sentinel lymph nodes with the addition of an ultrastaging processing protocol which may differ between laboratories.⁶

Submit omental tissue, 2 sections if grossly positive, if grossly negative submit 1 representative section per 2 or 3cm of maximal omental dimension (a minimum of 4 sections if grossly negative).⁶

Record details of each cassette.

An illustrated block key similar to the one provided may be useful.

Block allocation key

Cassette ID	Site	No. of pieces
A	Left parametrium sections
B	Right parametrium sections
C-D	Left fallopian tube
E-F G-H I-J	Right fallopian tube Left ovary Right ovary
K	Anterior cervix
L	Posterior cervix
M-P	Tumour, demonstrating deepest point of penetration, relationship with serosa and/or surgical margins
Q-R	Left and right cornu if involved
S	Isthmus, longitudinal section or contiguous sections to include inferior part of the tumour and cervical os
T	Background endometrium

 

Acknowledgements

Associate Professor Kerryn Ireland-Jenkin and Dr Marsali Newman for their contribution in reviewing and editing this protocol.

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References

1. Royal College of Pathologists of Australasia (RCPA) (2019). Cancer protocols. Available from https://www.rcpa.edu.au/Library/Practising-Pathology/Structured-Pathology-Reporting-of-Cancer/Cancer-Protocols. (accessed 14^th August 2019)
2. Ganesan R, Singh N and McCluggage WG. Dataset for histological reporting of endometrial cancer, The Royal College of Pathologists, London, 2017.
3. McCluggage WG, Fisher C and Hirschowitz L. Dataset for histological reporting of uterine sarcomas, The Royal College of Pathologists, London, 2011.
4. Brown L, Andrew A, Hirschowitz L and Millan D. Tissue pathways for gynaecological pathology, The Royal College of Pathologists, London, 2008.
5. Heatley MK (2008). Dissection and reporting of the organs of the female genital tract. J Clin Pathol 2008;61(3):241-257.
6. Malpica A, Euscher ED, Hecht JL, et al. Endometrial Carcinoma, Grossing and Processing Issues: Recommendations of the International Society of Gynecologic Pathologists. Int J Gynecol Pathol. 2019;38 Suppl 1(Iss 1 Suppl 1):S9–S24.